remote rural places there may be only one physician within a reasonable
distance.
Until the mid-20th century it was not unusual for the doctor in Britain to
visit patients in their own homes. A general practitioner might make 15 or
20 such house calls in a day. as well as seeing patients in his office or
"surgery," often in the evenings. This enabled him to become a family
doctor in fact as well as in name. In modern practice, however, a home
visit is quite exceptional and is paid only to the severely disabled or
seriously ill when other recourses are ruled out. All patients are normally
required to go to the doctor.
It has also become unusual for a personal doctor to be available during
weekends or holidays. His place may be taken by one of his partners in a
group practice, a provision that is reasonably satisfactory. General
practitioners, however, may now use one of several commercial deputizing
services that employs young doctors to he on call. Although some of these
young doctors may he well experienced, patients do not generally appreciate
this kind of arrangement.
United Stales. Whereas in Britain the doctor of first contact is regularly
a general practitioner, in the United States the nature of first-contact
care is less consistent. General practice in the United States has been in
a slate of decline in the second half of the 20th century especially in
metropolitan areas. The general practitioner, however, is being replaced to
some degree by the growing field of family practice. In 1969 family
practice was recognized as a medical specialty after the American Academy
of General Practice (now the American Academy of Family Physicians) and the
American Medical Association created the American Board of General (now
Family) Practice. Since that time the field has become one of the larger
medical specialties in the United States. The family physicians were the
first group of medical specialists in the
United States for whom recertification was required.
Theie is no national health service, as such, in the United Stales. Most
physicians in the country have traditionally been in some form of private
practice, whether seeing patients in their own offices. clinics, medical
centres, or another type of facility and regardless of the patients'
income. Doctors are usually compensated by such state and federally
supported agencies as Medicaid (for treating the poor) and Medicare (for
treating the elderly); not all doctors, however, accept poor patients.
There are also some state-supported clinics and hospitals where the poor
and elderly may receive free or low-cost treatment, and some doctors devote
a small percentage of their time to treatment of the indigent. Veterans may
receive free treatment at Veterans Administration hospitals, and the
federal government through its Indian Health Service provides medical
services to American Indians and Alaskan natives, sometimes using trained
auxiliaries for first-contact care.
In the rural United States first-contact care is likely to come from a
generalist I he middle- and upper-income groups living in urban areas,
however, have access to a larger number of primary medical care options.
Children are often taken to pediatricians, who may oversee the child's
health needs until adulthood. Adults frequently make their initial contact
with an internist, whose field is mainly that of medical (as opposed to
surgical) illnesses; the internist often becomes the family physician.
Other adults choose to go directly to physicians with narrower specialties,
including dermatologists, allergists, gynecologists, orthopedists, and
ophthalmologists.
Patients in the United States may also choose to be treated by doctors of
osteopathy. These doctors are fully qualified, but they make up only a
small percentage of the country's physicians. They may also branch off into
specialties, hut general practice is much more common in their group than
among M.D.'s.
It used to be more common in the United States for physicians providing
primary care to work independently, providing their own equipment and
paying their own ancillary staff. In smaller cities they mostly had full
hospital privileges, but in larger cities these privileges were more likely
to be restricted. Physicians, often sharing the same specialties, are
increasingly entering into group associations, where the expenses of office
space, staff, and equipment may be shared; such associations may work out
of suites of offices, clinics, or medical centres. The increasing
competition and risks of private practice have caused many physicians to
join Health Maintenance Organizations (HMOs), which provide comprehensive
medical. care and hospital care on a prepaid basis. Thе cost savings to
patient's are considerable, but they must use only the HMO doctors and
facilities. HMOs stress preventive medicine and out-patient treatment as
opposed to hospitalization as a means of reducing costs, a policy that has
caused an increased number of empty hospital beds in the United States.
While the number of doctors per 100,000 population in the United States has
been steadily increasing, there has been a trend among physicians toward
the use of trained medical personnel to handle some of the basic services
normally performed by the doctor. So-called physician extender services are
commonly divided into nurse practitioners and physician's assistants, both
of whom provide similar ancillary services for the general practitioner or
specialist. Such personnel do not replace the doctor. Almost all American
physicians have systems for taking each other's calls when they become
unavailable. House calls in the United Stales, as in Britain, have become
exceedingly rare.
Russia. In Russia general practitioners are prevalent in the thinly
populated rural areas. Pediatricians deal with children up to about age 15.
Internists look after the medical ills of adults, and occupational
physicians deal with the workers, sharing care with internists.
Teams of physicians with experience in varying specialties work from
polyclinics or outpatient units, where many types of diseases are treated.
Small towns usually have one polyclinic to serve all purposes. Large cities
commonly have separate polyclinics for children and adults, as well as
clinics with specializations such as women's health care, mental illnesses,
and sexually transmitted diseases. Polyclinics usually have X-ray apparatus
and facilities for examination of tissue specimens, facilities associated
with the departments of the district hospital. Beginning in the late 1970s
was a trend toward the development of more large, multipurpose treatment
centres, first-aid hospitals, and specialized medicine and health care
centres.
Home visits have traditionally been common, and much of the physician's
time is spent in performing routine checkups for preventive purposes. Some
patients in sparsely populated rural areas may be seen first by feldshers
(auxiliary health workers), nurses, or midwives who work under the
supervision of a polyclinic or hospital physician. The feldsher was once a
lower-grade physician in the army or peasant communities, but feldshers are
now regarded as paramedical workers.
Japan. In Japan, with less rigid legal restriction of the sale of
pharmaceuticals than in the West, there was formerly a strong tradition of
self-medication and self-treatment. This was modified in 1961 by the
institution of health insurance programs that covered a large proportion of
the population; there was then a great increase in visits to the outpatient
clinics of hospitals and to private clinics and individual physicians.
When Japan shifted from traditional Chinese medicine with the adoption of
Western medical practices in the 1870s. Germany became the chief model. As
a result of German influence and of their own traditions, Japanese
physicians tended to prefer professorial status and scholarly research
opportunities at the universities or positions in the national or
prefectural hospitals to private practice. There were some pioneering
physicians, however, who brought medical care to the ordinary people.
Physicians in Japan have tended to cluster in the urban areas. The Medical
Service Law of 1963 was amended to empower the Ministry of Health and
Welfare to control the planning and distribution of future public and
nonprofit medical facilities, partly to redress the urban-rural imbalance.
Meanwhile, mobile services were expanded.
The influx of patients into hospitals and private clinics after the passage
of the national health insurance acts of 1961 had, as one effect, a severe
reduction in the amount of time available for any one patient. Perhaps in
reaction to this situation, there has been a modest resurgence in the
popularity of traditional Chinese medicine, with its leisurely interview,
its dependence on herbal and other "natural" medicines, and its other
traditional diagnostic and therapeutic practices. The rapid aging of the
Japanese population as a result of the sharply decreasing death rate and
birth rate has created an urgent need for expanded health care services /or
the elderly. There has also been an increasing need for centres to treat
health problems resulting from environmental causes.
Other developed countries. On the continent of Europe there are great
differences both within single countries and between countries in the kinds
of first-contact medical care. General practice, while declining in Europe
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